Despite the pioneering contributions of psychiatrists to the family therapy field (e.g., Carl Whitaker, Murray Bowen, Salvador Minuchin), and recommendations to include family therapy training in psychiatry residency programs (
+1,
+2), neither residents nor medical students are exposed as much to family therapy training as they are to training in other treatment modalities (
+3,
+4). This training disparity may be due to the perceived incompatibility of family systems models with biomedical or psychodynamic models, or to the relatively small number of attending psychiatrists who identify themselves as family therapists, with a corresponding reluctance of training directors to use nonphysician supervisors (
+5). Nevertheless, some training in family therapy is now part of the core curriculum at most psychiatry residency training programs (
+3), usually offered in the third year during an outpatient adult psychiatry residency rotation or in child and adolescent psychiatry training (
+6). However, there is no consensus about how much training should be offered, when during the residency it should be provided, and how best to integrate family therapy concepts with established biomedical or psychodynamic models of patient care.
Evaluation of the impact of existing family therapy training during residency could assist faculty in making decisions about the nature, timing, and format of such training that would best serve future residents' training needs. In this vein, some authors have conducted surveys of psychiatrists to determine the extent to which they perceived their residency training in family therapy to have been useful and relevant to their professional practice. Carter (
+7—
+9) conducted several studies to systematically evaluate the effects of family therapy training on residents' subsequent practice of couple and family therapy. He concluded that couple and family therapy training significantly influenced a preference for family therapy practice. However, his conclusions are limited by a low response rate in one study (25% to 30%), and his failure to obtain a dose—effect response. Slovic et al. (
+10) conducted semistructured interviews with 59 graduates of two residency programs in child and adolescent psychiatry, obtaining excellent response rates (82% to 100%). They found that all graduates benefited from family therapy training but that respondents were currently using family therapy theory and skills less as a treatment modality than as a systemic framework for solving administrative and treatment-team problems. Slovik and colleagues concluded that residencies should redirect family therapy training curricula toward family-centered interventions across a range of treatment modalities rather than teaching family therapy as a single modality.
Using a large pool of respondents, Guttman et al. (
+11) obtained retrospective data from 291 psychiatrists (47% response rate) who graduated between 1962 and 1992 from the McGill University Diploma Course in Psychiatry. They derived a cumulative total training score for family therapy that included frequency of attendance at family therapy seminars, number of hours in family therapy supervision, number of family therapy sessions per week, and type of residency rotation. Higher family therapy total training scores were significantly associated with number of hours per week of family therapy practice and with perceived positive impact of family therapy training on the use of family therapy in current practice. Limitations of this study included the unknown psychometric properties of the total training score and the questionable validity of retrospective data based on memory of training completed 10 to 30 years ago.
With the exception of these evaluations of residency training in family therapy, relatively little attention has been paid to such training in psychiatry residencies. Yet many psychiatrists over the last 40 years have emphasized the importance of a systemic orientation to psychiatry and medicine (
+12—
+14). They have argued that psychiatrists are uniquely trained to conceptualize problems from a biopsychosocial perspective, which incorporates an understanding of how interpersonal variables influence and are influenced by individual biology, behavior, and experience.
In this vein, Combrinck-Graham (
+5) distinguishes between family therapy training and ecosystemic residency training, noting that the systems epistemology informing most family therapies has applications in psychiatry that are much broader than the practice of family therapy. She proposed a systemic training sequence for general psychiatry residents, with simultaneous presentation (in each year) of family therapy and the application of systemic concepts to other professional tasks. As a part of this training program, she recommends a weekly family interview or case conference conducted by a skilled, systems-oriented psychiatrist who elicits information about the family system and relates it to the resident's work with the index patient.
The interdisciplinary family evaluation is a similar training experience in family assessment and systemic conceptualization suitable for most residencies. In this mode of evaluation, trainees and a family therapy supervisor collaboratively conduct an extended assessment of the dynamic interplay between the index patient's presenting problem and his or her family patterns. This kind of family evaluation possesses four clear training advantages over other family therapy training formats. First, the family evaluation includes live supervision of trainees. Live supervision allows trainees to process interactions they may have missed, provides them with constructive feedback during the session so they can make midcourse corrections in the treatment, and models and shapes ways in which trainees can flexibly integrate relational and systemic perspectives into their existing theoretical models. A second advantage of the family evaluation is the opportunity to collaborate with an interdisciplinary team regarding case conceptualization. A third advantage is the greater breadth of training that can be achieved when greater numbers of patients are seen. Trainees attain broader exposure by assessing a different family each time they participate in a family evaluation—although the depth of understanding may be compromised by seeing each family only once. Still another advantage is that family evaluations may be less subject to patient attrition than ongoing family therapy. If the family evaluation includes systemically influenced outreach efforts, most family members will attend a one-time evaluation session. In contrast, it may be logistically more difficult for all family members to attend multiple therapy sessions (
+15,
+16).
This paper describes the training goals and structure of one type of family evaluation training in a child psychiatry clinic. We present patient attendance data and retrospective trainee perceptions about evaluations conducted during the academic years 1994—1999. These data are reviewed to determine the extent to which the family evaluation training goals have been met, as well as to assess 1) how helpful and valuable the training experience was for trainees, 2) for whom the training experience was most helpful, 3) the best timing of family evaluation training, and 4) ways to improve the family evaluation training experience.
Family Evaluation Clinic (FEC) is an extended, one-session family evaluation conducted by an interdisciplinary team in an outpatient child psychiatry clinic serving a predominantly low-income, African-American, urban population. Like the seminal Milan therapeutic interview format, FEC includes presession, session, intersession, intervention/feedback, and postsession components (
+17), modified to be culturally responsive to our patient population (
+18).
The presession consists of outreach to the family prior to the appointment, to obtain information about the presenting problem and family constellation, negotiate mutually agreed goals for the evaluation, and facilitate the family's attendance at the FEC appointment. The evaluation session is structured to include a family interview conducted by the team, followed by individual and subsystem interviews conducted by team members separately. Then the family is given a 20- to 30-minute break (intersession); during this time, team members discuss the case, develop a systemic formulation, and devise the feedback to be given to the family. After the break, the family returns to hear the team's feedback and recommendations for treatment. The session, intersession, and feedback collectively take about three hours. In the postsession, team members meet to debrief, write chart notes, and obtain feedback about their performance. Often, a letter summarizing the feedback is sent to the family during the next week.
The primary clinical goals of FEC are to 1) assess the role of family dynamics in the development, maintenance, and sequelae of the presenting problem, and 2) engage the family in the evaluation and treatment process. During the family interview, verbal and nonverbal techniques are used to elucidate family interaction patterns as well as understand family members' perceptions of the presenting problem. In contrast, the primary purpose of the individual and subsystem interviews is to begin to assess problems identified or observed in the family interview (e.g., depression, attention deficits). Individual/ subsystem interviews also offer family members a more private setting to express their concerns and share relevant information about the family.
The primary training goals of FEC are to 1) provide trainees with supervised clinical experience with traditionally hard-to-reach low-income families, 2) teach trainees how to engage families in an extended, one-time family evaluation, 3) increase trainees' comfort and skill in conducting an interview with a family group having more than two members, 4) help trainees to develop systemic conceptualizations of presenting problems in child psychiatry, and 5) assist trainees in working collaboratively as part of an interdisciplinary assessment team.
The setting for FEC is a large teaching hospital that serves as a primary training site for residency programs at the Emory University School of Medicine and the Morehouse School of Medicine. Neither of these residency programs includes compulsory, systematic training in family therapy. FEC uses an interdisciplinary team in which each evaluator's perspective on the family is woven into an assessment of the family's difficulties and recommended interventions. The team consists of an
attending psychologist (a nonphysician supervisor active in the child psychiatry residency program, used because of her expertise in evaluation of families with children; current training plans include the expansion of FEC to the general psychiatry residents' evaluations of children, supervised by a child psychiatrist trained by the FEC supervisor), a
psychiatry resident, and a
psychology trainee. Trainees of different levels and types of experience may work together and learn from each other in an interactive, collaborative co-therapy experience. Furthermore, as a trainee's clinical interviewing skills and conceptualization of family dynamics improves, she or he can take an increasingly active role in the evaluation, consistent with developmental models of family therapy training (
+5,
+19).
There are four clinician roles corresponding to increasing levels of participation in FEC: observer, interviewer, contact person with supervisor present, and contact person without the supervisor present. Observers are present during the family interview, subsystem interviews, and feedback portions of FEC. They are introduced to the family as part of the FEC team, but they do not typically participate verbally in the interview process. Interviewers conduct subsystem interviews but play a secondary role in the family interview and feedback portions of the evaluation. Contact persons conduct all the outreach efforts during presession, lead the family interview, interview the caregiver during subsystem interviews, and coordinate the feedback given to the family. Trainees serving in the role of contact person initially do so with their supervisor present during the entire evaluation. Advanced trainees with considerable FEC experience may serve as contact person without the supervisor meeting the family; in these cases, the supervisor is present only during presession, intersession, and postsession, when the case is discussed and conceptualized.
To assess patients' attendance rate, all charts for patients scheduled for FEC from August 1994 through June 2000 were reviewed. To assess trainees' perceptions of the utility and value of the FEC training program, a survey was developed and sent to trainees who participated in FEC during the same time period. The survey consisted of 16 precoded questions (Likert-type and others) and 3 open-ended questions that were coded by two independent raters. The precoded questions collected demographic information, assessed comfort levels with family assessment before and after the training, identified the most helpful and unique aspects of the training, and determined the value of the training in the respondent's current job. The open-ended questions elicited information about the most important lessons learned during the training, the benefits and challenges of being the contact person, and suggestions for improving FEC training.
+
Patient Attendance at FEC: 1994–2000
Families were selected for FEC from the list of patients awaiting initial appointments for an evaluation at the clinic, although a few families were referred directly to FEC from community agencies. Families on the clinic waiting list were considered for FEC if 1) the family had a home phone number, and 2) the intake information referred to siblings or multiple caregivers (two or more). In all, 119 families were scheduled for FEC during the period from 1994 to 2000; 6 families received a second appointment when they did not show up for the first, accounting for 125 scheduled evaluations. Ninety-three (74%) of the 125 scheduled evaluations were completed. As we focused more of our efforts on treatment engagement, our show rates improved: 81% (22 of 27) for the 1998-1999 academic year, and 83% (15 of 18) for the 1999-2000 academic year. These show rates are significantly higher than those reported for non-FEC evaluations conducted by residents. Of 64 consecutive cases assigned to psychiatry residents for individual evaluation at the same clinic from July through October 1998, only 24 (38%) showed up for their initial appointment. These cases are not substantially different from the cases assigned to FEC; these families also had home phone numbers, and many included siblings or multiple caregivers. However, there is little or no telephone outreach to these families. A secretary or a supervisor simply informs the caregiver of the appointment over the phone.
Patients seen in FEC were not demographically different from other families seen at the clinic. Most of the families (92%) scheduled for FEC were African American. Almost all received Medicaid. The number of family members present for FEC ranged from 2 to 12, with a mean of 5, whereas only 2 or 3 family members usually presented for individual child evaluations at the clinic. Thus, FEC presented most trainees with a unique opportunity to interview a relatively large family group.
+
Trainee Perceptions of FEC: 1994–2000
+
Characteristics of Trainees:
A total of 62 psychiatry and psychology trainees participated in FEC during the academic years 1994—1999. The number of trainees participating in a given FEC evaluation ranged from 1 to 3, with a mode of 2. Clinic records show that each trainee participated in an average of 2.74 FEC sessions. Because of differences between psychiatry and psychology training schedules, residents were generally assigned to FEC for shorter periods of time than psychology trainees. Thus, psychiatry trainees generally participated in 1 to 5 FEC sessions, whereas psychology trainees participated in 1 to 11 FEC sessions. The supervising psychologist usually was the contact person, although several trainees (15%) served as contact person at least once. Psychiatry residents rarely served in the contact person role because they were not assigned to the FEC rotation long enough to feel comfortable assuming greater leadership in the evaluations.
In July and August 2000, surveys were distributed to 57 of the 62 psychiatry and psychology trainees who participated in FEC during the academic years 1994—2000. Three trainees were not sent surveys because correct addresses could not be located for them. Two were not sent surveys because they are co-authors of this manuscript. Forty-two surveys were returned (21 psychiatry, 21 psychology), yielding an overall response rate of 74 percent. However, one of the psychiatry trainees returned a blank survey stating that she did not recall specifics about her FEC experience, yielding a total of 20 resident respondents. Survey respondents were primarily female (80%) and were racially diverse (46% Caucasian, 32% African American, 15% Asian, 2% Latino, and 2% Native African), consistent with the gender and ethnic minority distribution of the trainees. Respondents comprised a range of training levels (20% PGY-2, 2% PGY-3, 27% PGY-5 or -6, 15% psychology practicum students, 29% psychology interns, and 7% psychology postdoctoral fellows). Twenty-nine percent of respondents are still completing their degree programs, 17% are completing fellowships or postdoctoral training, 10% currently hold academic faculty positions, and 44% are involved primarily in clinical practice.
Respondents varied as to their previous family assessment and treatment experience prior to participating in FEC. Approximately 40% of the total sample had minimal previous experience (i.e., attending only a few lectures on family assessment/intervention); 40% had moderate previous experience (i.e., completing 1 family course and obtaining supervision on 0—5 family cases) and 20% had extensive previous experience (i.e., completing >1 course and obtaining supervision on >5 family cases). As a group, psychiatry residents had less previous family assessment and treatment experience than psychology trainees; the majority of psychiatry trainees (70%) had minimal experience, whereas the majority of psychology trainees (86%) had moderate to extensive experience. When asked about their reasons for participating in FEC, 5% of the respondents stated that they participated simply because it was required, 56% stated that although the training was required, they were interested in obtaining additional family experience, and 39% stated that they voluntarily participated in FEC.
+
Utility and Value of FEC:
Respondents overwhelmingly reported that the FEC training experience was helpful to extremely helpful to them, with 59% of respondents endorsing a 6 or 7 on a 7-point Likert-type scale (7=extremely helpful; mean=5.8, mode= 7). When asked to list the three most important things learned from participation in FEC, 88% of respondents spontaneously listed family assessment/treatment techniques (i.e., general or specific techniques such as joining, sculpting, circular questions), 24% listed family engagement techniques (i.e., telephone outreach, pre-visit contact), 24% listed systemic conceptualization skills, 22% listed the immediate feedback given to families, 17% listed the value of doing family assessments, 14% listed sensitivity to cultural issues, 12% listed collaboration and co-therapist interaction skills, and 12% listed helping families appreciate and improve on their strengths.
Comparisons between the psychiatry and psychology trainees related to their perceptions of the overall helpfulness of the FEC training did not reveal a significant difference (t=—1.5, P=0.13). Further, when asked to rate how helpful several specific aspects of the training were, both psychiatry and psychology trainees were positive, with mean ratings on a 7-point Likert-type scale ranging from 4.7 to 6.5. However, trainees did significantly differ on their views of how helpful it was to learn about giving feedback to families (t=—2.1, P=0.04). Although both groups were generally positive about this aspect of the training, with means above 5.7, the psychiatry residents rated giving feedback to families as significantly less helpful than the psychology trainees.
The respondents were asked to check off all components of the training they perceived to be unique to FEC from a list provided on the survey. For psychiatry trainees, the most commonly endorsed responses were simultaneous interviewing of all family members (90%), conducting a lengthy family assessment (75%), observing a faculty member conduct a live family interview (70%), and giving immediate feedback to families at the end of the session (65%). Only 25% of the residents endorsed sending feedback letters to the families or engaging families prior to the first session as unique aspects of the FEC training experience. In contrast, most of the psychology trainees (66%) endorsed sending feedback letters as a unique aspect of FEC training, and a minority (38%) endorsed observing a faculty member conduct a live family interview.
When asked what they learned about engaging families in treatment that they did not learn in other training experiences, respondents endorsed learning the importance of discussing and problem-solving barriers to attending the session (59%), applying a systemic conceptual framework to early outreach efforts (56%), providing the family with hope (44%), making early and frequent contact (42%), and finding ways to establish rapport prior to the first session (42%).
Respondents were asked to retrospectively rate their comfort level before and after their participation in FEC. Respondents' average comfort level on a 7-point Likert-type scale (1=not comfortable at all, 7=extremely comfortable) prior to FEC was 3.37 and following FEC was 5.52, yielding a statistically significant difference (t=—9.7, P=0.000) suggestive of increased comfort level following the training. Respondents were also asked to provide information related to how helpful their FEC training is in their current work. The average estimated percentage of time respondents currently spend working with families is 29% across a variety of clinical contexts (27% for psychiatry trainees, 31% for psychology trainees). The majority of respondents reported that FEC is valuable to extremely valuable in their current work, with 54% of respondents endorsing a 6 or 7 on a 7-point Likert-type scale (7=extremely valuable; mean=5.4).
+
For Whom is FEC Most Helpful?
A second aim of the study was to determine if variables such as professional discipline, current position, or previous family experience differentially affected the self-reported value and utility of the FEC training experience. Results of t-tests and chi-square analyses demonstrated that there were no significant differences between psychiatry and psychology trainees in regard to the overall helpfulness of FEC, the value of FEC training in their current work, or the increase in comfort level in working with families attained following their FEC experience. Similarly, no significant differences were found between those trainees who served as contact persons during FEC (22%) and those who did not. However, there was a slight trend toward those individuals who served as contact persons perceiving that the FEC training was more helpful to them (χ2=16.7, P=0.08).
In addition, several t-tests and analyses of variance were run to determine if various trainee variables (previous family experience, current job, reason for participating in FEC, time since FEC participation, level of training) affected respondents' perceptions of FEC. No significant differences were found for the helpfulness or value of FEC, or for the increase in comfort level in working with families. The only trainee variables found to be associated with FEC perceptions were reason for participating in FEC and, for psychiatry trainees, year of training. Specifically, those who voluntarily chose to participate in FEC reported a higher value of their FEC training in their current work than those who were required to participate in FEC (F=3.8, P<0.05). For psychiatry trainees, residency year of FEC training was related to perception of FEC as helpful; second- and third-year residents reported the FEC training to be more helpful than the advanced (fifth- or sixth-year) child psychiatry residents (t=2.34, P<0.05). This difference does not appear to be due to differential clinical experience, as t—tests did not show differences between the two groups in reported previous family therapy experience (t=—1.0, P=0.33).
+
Preferred Intensity and Timing of FEC Training:
When asked how satisfied they were with the number of FEC cases they were involved with, 88% of respondents replied that they wished they could have been involved in more FEC cases during their training. The most common barriers preventing additional involvement in FEC included competing demands in the trainee's training programs (66%), client no-shows (63%), an excess of available trainees requiring that one trainee sit out (24%), and personal scheduling conflicts (15%).
Twenty-two percent of respondents served as contact persons during their FEC training experience. Responses to open-ended questions about the benefits of being a contact person included the following: attainment of a more enriching learning experience through putting what they learned into practice and having to thoughtfully prepare for the session (78%), gaining a deeper understanding of family conceptualization skills (22%), obtaining a stronger alignment with the family (11%), and having more independence (11%). The reported challenges of being a contact person included difficulties engaging the family (i.e., building rapport, maintaining contact, ensuring attendance; 67%), having to think on your feet during the session (33%), and employing successful family assessment and intervention techniques (22%). All of these respondents reported that they were asked to take on the contact person responsibility at an appropriate time, when they felt ready. Forty-six percent of those who did not serve as contact person wished that they had had an opportunity to do so during their FEC training experience. However, the most common barriers preventing them from being contact persons included failing to observe enough FEC sessions to be prepared (47%) and not having the time to take on the responsibility (22%).
With regard to the ideal timing for FEC training for psychiatry residents, the respondents had quite diverse perspectives. The majority replied that FEC training should be offered throughout their training (30%). However, other respondents stated that the best time for FEC training would be PGY-2 (15%), PGY-3 (20%), PGY-4 (5%), the first year of child psychiatry fellowship (15%), or the second year of child psychiatry fellowship (15%).
+
Suggestions for Improving FEC Training:
Responses to the question about what aspects of the FEC training program should be improved were analyzed separately for psychiatry and psychology respondents. For residents, the top responses endorsed were to increase amount of FEC training (85%) and to involve trainees more during each FEC session (55%). A minority of residents endorsed the following responses: involve psychiatry faculty (25%), lengthen the training experience to include more families and more follow-up of evaluated families (10%), specific suggestions to improve the training experience (i.e., more time for formulation and discussion, using videotape for training purposes, starting psychiatry residents before they have a heavy outpatient schedule; 20%), and suggestions to improve patient attendance (15%). Responses from psychology trainees were similar, except that only 19% suggested that trainees should be more involved in each FEC session.
FEC is an innovative method for teaching family systems concepts and techniques to psychiatry residents, particularly those in outpatient clinics serving the urban poor, where high no-show rates can waste valuable training time. Over a period of 6 years, our FEC evaluations yielded a show rate almost double that of the residents' non-FEC evaluations in the same clinic (73% vs. 38%). The higher patient attendance rate for FEC is likely due in part to the telephone outreach conducted by the contact person prior to the appointment. It should be noted, however, that these outreach efforts were guided by a systemic conceptualization, which may account for the presence of multiple family members (mean=5) at FEC. Telephone outreach alone (e.g., reminder calls) with the non-FEC cases probably would not have resulted in attendance of multiple family members at the patient's appointment, although this hypothesis was not tested in the present study.
Thus, FEC appears to have achieved its goal of providing trainees with supervised clinical experience with families that are traditionally difficult to engage in treatment. In addition, the survey data from trainees indicates that respondents learned the importance of many aspects of treatment engagement: the need for early and frequent patient contact prior to the evaluation, applying a systemic conceptual framework to early outreach efforts, addressing barriers to appointment attendance, and the importance of gaining rapport prior to the session.
The FEC experience also appears to have increased trainees' comfort with and skills in family assessment. Psychiatry and psychology trainees reported that their FEC experiences during training were very helpful, especially in teaching specific family therapy and family assessment techniques. In addition, psychiatry residents had what was for them the unique experience of simultaneously interviewing multiple family members—an experience only 10% of psychiatry trainees reported having on other rotations or services during the rest of their residencies. Not only did our trainees find their FEC experience to provide unique training opportunities, they also reported that the experience significantly increased their comfort with interviewing families. Further, most trainees have found the FEC training experience to be valuable in their current work with patients and families, consistent with previous surveys of psychiatrists who received family therapy training during residency (
+7—
+11).
Although our psychiatry residents reported comparatively less family therapy training experience prior to FEC than our psychology trainees, there were no differences between the two groups in the perceived value or utility of FEC training. This finding suggests that FEC may be a good training experience for trainees of varying disciplines and levels of family therapy training. There is some evidence that second- and third-year residents benefited more from the FEC training than the advanced child residents, and that this differential benefit is not due to differential experience in family therapy. Although most training experiences are ideally offered earlier rather than later in residency training, there may be unique advantages of early family evaluation training. Participation in family evaluation training early in the residency may prevent difficulties in integrating family therapy concepts with established biomedical or psychodynamic models of patient care. In addition, earlier family evaluation training may help the trainee to feel more comfortable interviewing families as part of a child or adult patient's treatment later in the residency, when the trainee has achieved more clinical independence.
Our conclusions about the training benefits of FEC are limited by the retrospective nature of the trainee data, the small sample size, and the different time periods used for comparison of appointment attendance. Comparison of trainee reports of comfort and skill in family assessment obtained before and after FEC participation would have provided a more valid test of FEC than the retrospective reports we obtained. Retrospective data from trainees who completed FEC from 1 month to 5 years ago also introduces potential confounds of memory and recall. However, the use of retrospective surveys is a relatively inexpensive and convenient way of achieving an initial evaluation of a new program. Alternatively, the training benefits of FEC could have been better tested with an experimental design in which FEC trainees were compared with trainees who did not receive FEC training. However, an experimental design was not realistic or scientifically feasible in the context of our training schedule, where the risk of contamination was high. Further research on the training benefits of FEC should use a pre—post design and a larger sample. Our conclusion about the comparative success of FEC in eliciting high show rates is limited by the use of differential time periods for assessment of appointment attendance. Ideally, FEC appointment attendance rates should be compared with rates for a demographically and diagnostically similar sample of patients obtained over the same time period and at the same clinic as FEC.
Partly on the basis of our survey data, we recommend this FEC model as an effective and practical way of addressing the need for improved systemic training in psychiatric general residency programs. FEC training during the second and third years of general residency, scheduled for one-half day every other week for at least 2 to 3 months, may provide optimal training benefits. A 2- to 3-month period of training would allow trainees sufficient experience with FEC that each trainee would be able to serve as the contact person for at least one family, a role our trainees reported as useful. This training schedule would address our residents' suggestions that FEC training time be increased and would allow trainees even more involvement.
In addition, we recommend including a psychiatrist supervisor in the FEC training program. A quarter of our residents indicated that they would value increased involvement of psychiatry faculty in FEC supervision. Psychiatrist supervisors can serve as role models to the residents, demonstrating the contribution of psychiatry to the biopsychosocial continuum of patient care (
+5). The availability of alternating psychologist and psychiatrist supervisors, however, offers trainees from both disciplines the necessary modeling as well as greater breadth and diversity in applying the systemic model.
The FEC model is best integrated within a family therapy training program in which trainees participate in didactics on theories of family therapy prior to and concurrently with FEC. Although FEC provides a useful introduction to clinical applications of systemic thinking, it does not fulfill psychiatry residents' family therapy training needs. Residents require additional clinical training, including long-term, in-depth work with a variety of troubled families.
The FEC model is not without drawbacks. As an evaluation method, FEC is quite time-intensive, requiring one team member to spend significant time on the phone prior to the first session. There is also the question of reimbursement for the extended evaluation, which may be billable only by the attending. These concerns are valid, but they need to be weighed against the wasted resources incurred by high no-show rates. Furthermore, it should be noted that supervision and attending input are built into FEC itself; only in unusual circumstances are extra supervision hours required. Supervision thus is economical and efficient while remaining clinically relevant, as the FEC supervisor provides on-the-spot intervention and actively guides case formulations.
Clearly there is a need for further investigation of how best to provide family therapy training to psychiatry residents. We hope to institute changes in our residency training based on our survey data and then reexamine the perceived training benefits. It would also be important to determine the extent to which the FEC model proves effective in other training programs or in different clinical settings (e.g., an adult outpatient clinic). Similarly, future studies may compare FEC training with other methods for training psychiatry residents how to think systemically about patient care This is, in fact, the ultimate goal of our proposed FEC training: that residents begin to appreciate and understand how biological, psychological, and social factors interact in dynamic ways in the lives of their patients.